There are approximately 103,000 patients waitlisted for a kidney transplant in the United States; in 2018, only 14,725 patients received a deceased-donor kidney transplant. The scarcity of available kidneys for transplantation and the high mortality rate among patients awaiting transplant have led to interest in transplanting organs that might have been considered ineligible, including kidneys from hepatitis C virus (HCV) antibody-positive donors.
Discard rates of HCV-viremic kidneys are declining; however, approximately 39% of HCV-viremic kidneys donated between 2018 and 2019 were discarded. Chronic HCV infection can be managed with the highly effective antiviral agents that are now available. Mark H. Eckman, MD, MS, and colleagues conducted a study to examine the cost-effectiveness of transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients. Results of the study were reported Using Kidneys from HCV-Viremic Donors Is Cost-Effective in the American Journal of Kidney Diseases [2020;75(6):857-867].
The study utilized the Markov state transition decision model. Data sources included research of a Medline search, bibliographies from relevant English language articles, the Scientific Registry of Transplant Recipients, and the US Renal Data System. The study population included US patients receiving maintenance hemodialysis and on kidney transplant waiting lists. Study interventions were transplantation with an HCV-unexposed kidney versus transplant with an HCV-viremic kidney and HCV treatment. The outcomes of interest were effectiveness measured in quality-adjusted life-years (QALYs) and costs measured in 2018 US dollars.
Results of a nondiscounted base-case analysis demonstrated that transplantation with an HCV-viremic kidney improved survival by 1.19 QALY.
The study included extensive sensitivity analyses. As transplantation with HCV-viremic kidneys becomes more widely accepted over the coming years, the waiting time for transplant with such an organ will decrease. In the base case, the average waiting list time for an HCV-viremic kidney is 1.56 years, while the wait for an uninfected kidney is 4 years. Results of sensitivity analyses demonstrate that transplantation with an HCV-viremic kidney continues to result in a gain in quality-adjusted survival as long as the average waiting time is less than 3.79 years (<1383 days), corresponding to a decrease in waiting time of at least 0.21 year (77 days) given the average waiting time for an uninfected kidney is 4 years.
The researchers conducted a two-way sensitivity analysis of waiting list time for an HCV-viremic kidney and annual excess rate post-transplant of an HCV-viremic kidney. That analysis was designed to explore the possibility that HCV-viremic kidneys from young otherwise healthy donors dying from opioid drug overdose may be of higher quality, thus decreasing the annual excess mortality attributable to transplantation. Analysis results suggested that if the excess annual mortality following receipt of such a kidney is actually lower than that of the average kidney transplant (0.02/year), transplantation with an HCV-viremic kidney may still be the better strategy even for longer wait list times. Conversely, if future experience with transplantation of HCV-viremic kidneys suggest higher than average annual excess mortality, shorter waiting list times will be necessary to make this strategy optimal.
In economic analysis, transplantation with an HCV-viremic kidney improved survival by 0.91 QALY at a lifetime cost savings of $37,918 compared with a strategy of kidney transplantation with an HCV-unexposed kidney. In nondiscounted analysis, compared with transplantation of an HCV-unexposed kidney, transplantation with an HCV-viremic kidney improved survival by 1.19 QALY at a lifetime cost savings of $45,651.
Results of multiple one-way sensitivity analyses suggested that while transplanting an HCV-viremic kidney is cost saving and more effective in the base case, beyond a waiting list time of 2.67 years (975 days), transplantation with an HCV-viremic kidney is no longer cost saving, but remains highly cost-effective (incremental cost-effectiveness ratio < $50,000 per QALY) unless the wait time exceeds 3.1 years (1132 days). These results correspond to an additional wait list time of 0.9 year (329 days) compared with receipt of an HCV-unexposed kidney. The wait list time for an HCV-unexposed kidney is 4 years.
The parameter that had the most impact on the economic analysis was the cost of direct-acting antiviral (DAA) treatments for HCV infections. In the event that the cost for DAA regimens decreases to $7000 per month (from the base case value of $9830), the cost savings associated with transplantation of HCV-viremic kidneys would increase to $44,671.
There were some limitations to the findings cited by the authors, including estimating wait list times for patients willing to accept an HCV-viremic kidney based on data for patients who received HCV-viremic kidney transplants, and performing the analysis from the perspective of HCV-uninfected individuals considering transplantation.
In summary, the researchers said, “The tragedy of the opioid epidemic has resulted in potential donors who are younger and have few other medical comorbid conditions beyond chronic HCV infection. Using these kidneys to decrease waiting times can result in improved survival and cost savings. However, waiting times vary dramatically from patient to patient and from center to center. As shown in our scenario analyses for individual patients, transplantation of HCV-viremic kidneys in patients with shorter waiting times for HCV-unexposed kidneys may not result in a new benefit. What is needed is a decision support tool that can aid patients and their physicians in making the best choice, based on waiting time estimates for both HCV-unexposed and HCV-viremic kidneys using patient-specific clinical, demographic, and center-specific information. One could imagine using these individualized predictions, along with individual patient values and preferences for health states such as life on dialysis or after kidney transplantation with an HCV-viremic or HCV-unexposed organ, to inform a decision analytic model, such as that described in this study. The day is not far off when decisions to use previously discarded HCV-viremic kidneys can be optimized for individual patients through data-informed shared decision-making discussions using such tools.”
- Fewer than 4% of patients with kidney failure receive kidney transplantation due to a scarcity of available kidneys. Approximately 39% of hepatitis C virus (HCV)-viremic kidneys donated between 2018 and 2019 were discarded.
- Researchers used the Markov state transition decision model to examine the cost-effectiveness of transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients.
- Compared with transplanting kidneys from HCV-unexposed donors, using HCV-viremic kidneys increased quality-adjusted life expectancy and reduced costs.